Cindy M. L. Hutnik

Selective Laser Trabeculoplasty as Initial and Adjunctive Treatment for Open-angle Glaucoma

PurposeTo investigate the efficacy and safety of selective laser trabeculoplasty as an initial treatment for newly diagnosed open-angle glaucoma, and its role as adjunctive therapy. Patients and MethodsA prospective multicenter nonrandomized clinical trial was performed. Patients with newly diagnosed open-angle glaucoma or ocular hypertension were assigned to the primary (selective laser trabeculoplasty) treatment group or the control (latanoprost) group according to patient choice. Both groups were followed up at 1, 3, 6, and 12 months. A secondary treatment group was also included to study the efficacy of selective laser trabeculoplasty for patients intolerant of medical therapy or in whom such therapy was unsuccessful, with or without a history of previous argon laser trabeculoplasty. ResultsOne hundred eyes (61 patients) were enrolled, 74 in the primary treatment group and 26 in the control group. The average absolute and percent reductions in intraocular pressure for the primary treatment group were 8.3 mm Hg or 31.0%, compared with 7.7 mm Hg or 30.6% for the control group (P=0.208 and P=0.879). The responder rates (20% pressure reduction) were 83% and 84% for the primary and control groups, respectively. There were no differences in intraocular pressure lowering with selective laser trabeculoplasty on the basis of angle pigmentation. A modest contralateral effect was observed in the untreated fellow eyes of patients undergoing selective laser trabeculoplasty. ConclusionsSelective laser trabeculoplasty was found to be equally efficacious as latanoprost in reducing intraocular pressure in newly diagnosed open-angle glaucoma and ocular hypertension over 12 months, independent of angle pigmentation. Nonsteroidal antiinflammatory therapy had similar efficacy to steroids after laser therapy. These findings support the consideration of selective laser trabeculoplasty as a first-line treatment for newly diagnosed open-angle glaucoma or ocular hypertension.

Phacoemulsification and goniosynechialysis in the management of unresponsive primary angle closure.

Purpose:To evaluate the effectiveness of phacoemulsification and goniosynechialysis (PEGS) in managing acute and subacute primary angle closure unresponsive to conventional therapy. Materials and Methods:Retrospective series of patients of six glaucoma-trained surgeons with primary angle closure that did not respond to medical management, Nd:YAG laser peripheral iridotomy, or argon laser peripheral iridoplasty. Results:A total of twenty-one patients with an average age of 65.6 years were included. Underlying mechanism of angle closure included pupillary block (n = 18) and plateau iris (n = 3). Average intraocular pressure (IOP) immediately prior to PEGS was 40.7 mm Hg, and mean follow-up time after PEGS was 11.7 months. PEGS decreased mean IOP by 25 mm Hg (62%), and mean number of medications from 3.8 pre-surgery to 1.7 post-surgery (55%). Mean LogMar visual acuity improved after PEGS, from 0.64 to 0.44 (Paired t test t = 4.120 P = 0.001). Subsequent trabeculectomy was necessary in one case (5%). Conclusions:Phacoemulsification with goniosynechialysis may be an effective treatment option for primary angle closure unresponsive to conventional therapy.

Projected cost comparison of selective laser trabeculoplasty versus glaucoma medication in the Ontario Health Insurance Plan

BACKGROUND The projected 6-year cost comparison of primary selective laser trabeculoplasty (SLT) versus primary medical therapy in the treatment of open-angle glaucoma for Ontario patients aged 65 years or more is presented. Costs are taken from the perspective of the Ontario Health Insurance Plan at a per-patient level. METHODS The cost of each medication was obtained from the 2003 Ontario Drug Benefits formulary. The average annual cost of medications was determined by estimating the provincial prescription rate of glaucoma medications, with reference to both a volume-per-bottle study of these drugs and a study of pharmacy claims reports. A representative provincial prescription rate was calculated by reviewing 707 patient charts selected randomly from 5 ophthalmologic practices across Ontario. Medication therapies were categorized into mono-, bi-, and tri-drug therapy groups. The cost of SLT was analyzed under the following 2 scenarios. SLT rep 2y assumed a duration of 2 years before repeat SLT was necessary. SLT rep 3y assumed a duration of 3 years before repeat SLT was necessary. Bilateral 180 degrees SLT treatment and repeatability of SLT was assumed. The cost of surgery for patients who fail SLT or medical therapy was not accounted for in this study nor was the cost of patients who required medical therapy in conjunction with SLT. RESULTS In the SLT rep 2y scenario, the use of primary SLT over mono-, bi-, and tri-drug therapy produced a 6-year cumulative cost savings of 206.54 dollars, 1668.64 dollars, and 2992.67 dollars per patient, respectively. In the SLT rep 3y scenario, the use of primary SLT over mono-, bi-, and tri-drug therapy produced a 6-year cumulative cost savings of 580.52 dollars, 2042.82 dollars, and 3366.65 dollars per patient, respectively. INTERPRETATION Our findings suggest that SLT as primary therapy, at a per-patient level, offers a modest potential cost saving over primary medical therapy in the management of open-angle glaucoma for Ontario patients aged 65 years or more.

Comparison of the In vitro Safety of Intraocular Dyes Using Two Retinal Cell Lines: A Focus on Brilliant Blue G and Indocyanine Green

PURPOSE To compare the in vitro toxicity of brilliant blue G (BBG), indocyanine green (ICG), Trypan blue (TB), and Evans blue (EB) in a human retinal pigment epithelial cell line (ARPE-19) and a murine retinal ganglion/Muller glial (RGC) primary cell culture. DESIGN In vitro cell biology experimental study. METHODS The dose-dependent toxicity of the dyes was determined by exposing each dye at four different concentrations to the two cell cultures for a short exposure (three minutes) and a medium exposure (30 minutes). The time-dependent toxicity of the dyes was also determined. All four dyes, each diluted to 1/500th of stock concentration, were applied only to the ARPE-19 cells for a prolonged exposure of two, 24, 48, and 72 hours. Cell viability was measured via a mitochondrial dehydrogenase assay. RESULTS BBG was the only dye to cause toxicity in the ARPE-19 cell line at short exposure times. BBG and TB demonstrated toxicity at medium exposure times. BBG and ICG demonstrated toxicity at long exposure times and dilute concentrations. At short exposure times, none of the dyes caused toxicity in the RGC mixed primary cultures. In contrast, at medium exposure times, all dyes except ICG demonstrated toxicity that lessened with lower concentrations. CONCLUSIONS All dyes demonstrated relatively safe viability profiles in both cell lines at surgically relevant concentrations and times. Cell toxicity could be elicited at higher concentrations and longer exposure times. ICG had a favorable viability profile at almost all of the concentrations and times tested.

Projected cost comparison of Trabectome, iStent, and endoscopic cyclophotocoagulation versus glaucoma medication in the Ontario Health Insurance Plan.

Purpose:To compare the direct cost of treating glaucoma patients with Trabectome, iStent, and endoscopic cyclophotocoagulation (ECP) versus topical medications in Ontario, Canada. Costs are projected over a 6-year period, and presented on a per-patient level from the perspective of the Ontario Health Insurance Plan (OHIP). Methods:The per-bottle cost of each medication was obtained from the 2011 Ontario Drug Benefit (ODB) formulary. A wastage adjustment fee was added to the cost, as was a pharmacy markup, and an ODB dispensing fee. Previously published medication prescription rates were used to determine the frequency with which each medication is prescribed. We estimated the overall cost by taking a weighted average of the cost of each class of glaucoma medications.The cost of each glaucoma device was determined by contacting local distributors. We then added the cost of disposables used during surgery (viscoelastic and keratome) to the cost of each procedure. Start-up costs for each device and surgeons’ fees were excluded from the overall cost. Results:At 6 years, treatment with the Trabectome offered a cumulative cost savings of

A randomized clinical trial of selective laser trabeculoplasty versus argon laser trabeculoplasty in patients with pseudoexfoliation.

279.23,

Lacritin Rescues Stressed Epithelia via Rapid Forkhead Box O3 (FOXO3)-associated Autophagy That Restores Metabolism

1572.55, and

iStent as a Solo Procedure for Glaucoma Patients: A Systematic Review and Meta-Analysis.

2424.71 per patient versus monodrug, bidrug, and tridrug therapy, respectively. A cumulative cost difference of −

Needs assessment of ophthalmology education for primary care physicians in training: comparison with the International Council of Ophthalmology recommendations

20.77,

iStent with Phacoemulsification versus Phacoemulsification Alone for Patients with Glaucoma and Cataract: A Meta-Analysis

1272.55, and